Provider Demographics
NPI:1255466512
Name:LOUISVILLE JEFFERSON COUNTY METRO GOVERNMENT
Entity Type:Organization
Organization Name:LOUISVILLE JEFFERSON COUNTY METRO GOVERNMENT
Other - Org Name:NEWBURG HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSM
Authorized Official - Phone:502-574-6580
Mailing Address - Street 1:400 E GRAY ST
Mailing Address - Street 2:P. O. BOX 1704
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1740
Mailing Address - Country:US
Mailing Address - Phone:502-574-6514
Mailing Address - Fax:502-574-6417
Practice Address - Street 1:4810 EXETER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3874
Practice Address - Country:US
Practice Address - Phone:502-458-1215
Practice Address - Fax:502-456-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251K000004251K00000X
261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1051422OtherPASSPORT MANAGED CARE NUM
KY20056131Medicaid
KYFLU0276Medicare ID - Type UnspecifiedFLU SHOT ONLY NUMBER